Gasoline Credit Card Request Form
Instructions/Purpose: Use this form to request a gasoline credit card. The completed form must be signed by the Dean, Director, or Department
Chair and forwarded to the purchasing office on your campus. Be advised that the department is responsible for all charges and the subsequent
payment on the card(s).
Camden: Purchasing Department, Administrative Services Building, 409 N. 4th Street, Camden, NJ 08402-1406
New Brunswick: Purchasing Department, Administrative Services Building III, 3 Rutgers Plaza, New Brunswick, NJ 08901-8559.
Newark: Purchasing Department, Blumenthal Hall, 2nd Floor, 249 University Avenue, Newark, NJ 07102
Requestor Name:
Requestor Phone Number:
Department Name:
Campus:
Camden
Douglass
Busch
Livingston
Cook
Newark
CAC
Department Address:
License Plate of Vehicle:
Vehicle Make:
Vehicle Model:
Type of Gasoline Credit Card Requested
Exxon/Mobil
Gulf
Shell/Texaco
Sunoco
Pin Number
All accounts require a driver pin number that must be input at the time of gasoline purchase. Please indicate your preferred, four digit pin number
below.
Purpose for Requesting Card(s):
Requestor Signature: _______________________________________________________ Date: _____________________________________
Dean, Director, or Department Chair Signature: _______________________________________________ Date: ________________________
By signing above, the Requestor and the Dean/Director/Department Head attest to their understanding and acceptance of the
Gasoline Credit Card Guidelines.
Revised: March 30, 2005